Objectives: Students: Residents Pediatric Fellows Nurses Paramedics Pediatric Faculty Adult Faculty Move EM ultrasound forward Around the World

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1 Cardiac Arrest Dave Spear, MD, FACEP Parkland / Children s Medical Center Dallas UT Southwestern School of Medicine Copyright All Rights Reserved 2002 Objectives: Cardiac Arrest History of ER Cardiac Cardiac Contraction Unexplained Hypotension Arrythmias Pacemaker Placement Pulmonay Emboli 2 Dave Spear, MD FACEP Ambulance Driver Paramedic Residency in Emergency Medicine Board Certified EM and Forensic Med ER MD Odessa 14 years Chief Medical Examiner Odessa, Texas ER MD Harris Methodist Fort Worth Parkland Emergency Director Children s Hospital of Dallas 3 Dave Spear MD FACEP My Jobs / Goals: Spread the word Teach Residents Teach Pediatric Fellows Teach Nurses Teach Paramedics Move EM ultrasound forward Around the World Students: Residents Pediatric Fellows Nurses Paramedics Pediatric Faculty Adult Faculty Move EM ultrasound forward Around the World is the: First thing that you should do to a Patient Fetus And the last thing you do to a Patient Cardiac Arrest Pronouncement 4 5 Cardiac Arrest What is it? 7 Cardiac Arrest: Has the heart arrested Denver - Cor Zero Is a Misnomer Paul Pepe We Mean Loss of Vital Signs Cardiac Arrest is an Echo Dx 8 Top reasons for U/S in a Code : 1. Is the heart contracting? 2. Is there a cardiac tamponade? 3. Is this PEA? 4. What is the rate of contraction? 5. What is the quality of contraction? 6. Do we continue with the Code? 7. What treatment modality we continue with? 8. Are we going to Cool the patient? 9. Pediatrics How hopeless is this resuscitaion? 10. Does this patient have a chance of survival? 11. Is this a PE? 9

2 10 AHA 2011 Guidelines: Cardiac Arrest More concentration on Chest Compression Shorter Pulse Checks Avoid interruption of Chest Compressions Wish to be consistent with these goals interrogation is short Scan during CPR What s new in this area? 1. Songram Machine 2. Defibrillator Monitor What s new in this area? 1. Songram Machine 2. Defibrillator Monitor Another Example: We can watch cardiac motion During CPR 13 For example, if you have a EKG Rhythm and No Pulse (PEA), 14 All efforts should be towards getting the heart moving and regain the pulse 15 For U/S During CPR: Place a dry washcloth over the central chest CPR places hand on chest Can use gel around washcloth Chest Compressions Chest Compressions

3 19 No Cardiac Motion Weak Cardiac Motion Normal Cardiac Motion Trans esophageal Echo Cardiac Plummer et, al. Hennepin County Medical Center Got Cardiac into ER Result of Increased Penetrating Trauma Happened in the 1980 s in Minneapolis Cocaine became popular What Comes to You: From EMS Dropped Off Walks In Copyright All Rights Reserved Emergency Medicine Dilemma Consider the Worst DX First Which of our patients are really sick or injured? 25 You are called to 28 yo Male Aryian Neo Nazi Meth user who shot up and missed two days ago and now hypotensive 26 The patient has no other complaint. His initial blood pressure is 95/50, Pulse of 110 and respiratory rate of 30. He arrests as he being unloaded from the ambulance. An ultrasound is performed: 27

4 Main Reasons for the US in EM: 1.) Bedside Screening Exams 2.) Bring the Machine in the room on an injured or Sick Patient 3.) Diagnose on High Index Cases 4.) Assist with Emergency Cardiac Cases Pattern of Use: 70% Pregnancy / Abd Pain 15% Trauma 15% Cardiac (Excluding Procedures) 31 Why Now? 32 Sonogram machines have gone from 400 lb to 5 lb 33 Ultraportable U/S Sonoscope For Cardiac Scans: Which Way will you Turn the Transducer? Three Points of View Abdominal Stand on Pt s Right Cardiac Echo Pt s Left Pt Rolls to Left Pedi Cardiologist View like a Anatomical Fig. 34 Copyright All Rights Reserved

5 Anatomic For Cardiac Scans: Which Way will you View the Image? Cardiologist Pediatric Cardiologist Pedi Card Anatomic Cardiac Probe Positions: Subcostal also has the liver as a window Adult Cardiologist Cardiac Probe Positions: Whether you call it: It is about Echocardiogram L Parasternal Shoot between the 5 th and 6 th ribs 40 Sonogram it is the same concept 41 Cardiac Motion 42 We will be doing a cardiac screen noting whether there is: No Cardiac Motion Weak Cardiac Motion Normal Cardiac Motion Concept 1 Cardiac Motion translates to: The Squeeze

6 46 The Squeeze What is it? Normal Squeeze Weak Squeeze No Squeeze The Squeeze Where do you best image it? You can view Cardiac Motion from: Subcostal L Parasternal One of these two views should give a good image Subcostal L Parasternal 52 You will want to quickly determine which of these two views gives the best image Subcostal Left Parasternal 53 The two images look like this: Subcostal L Parasternal 54

7 55 In motion: Subcostal In motion: Left Parasternal The Squeeze What does this tell us? The motion of the heart gives us a idea of: How the heart is contracting The Strength of contraction The Rate of contraction 58 Cardiac Contraction Ejection Fraction The Squeeze Estimation made Visually Can do formal Measurement Echo techs get all info in first few seconds 59 Acute MI Cardiac Function Hemorrhage into Pericardium Exudate in Pericardium Arrhythmia Congestive Heart Failure Ventricular Trauma Pedi Normal Squeeze Weak Squeeze No Squeeze

8 64 Cardiac Problems on Pericardial Tamponade A Special Case is Easy to see on sonogram: Massive Pericardial Effusion There is ring of fluid around the heart This fluid is an excellent window The heart motion can be seen in the pericardial fluid Pedi Look for pericardial effusion Jetblack (anechoic) stripe completely surrounding the heart. Pitfalls - Pericardial Effusion What could look like a pericardial effusion? Left Pleural Effusion Ascites When does effusion become Tamponade? Echo Tamponade Clinical Tamponade ACLS technique?

9 Where do you insert the needle? What needle do you use? Can have a specific Kit How much do you withdraw? How often do they present? Look posertior Cardiac Arrhythmias PEA Asystole VFIB 75 Summary Cardiac Sonograms: Are portable Can be rapidly performed Give us cardiac motion information SUMMARY (cont) and Cardiac Motion helps to direct patient care Reality of ER Cardiac: I Use it all the time Take my licks on fine details Can t Mess Up Some of our images make a cardiologist cringe THE END Questions? 79 80